Examination of Varicose Veins (S Das)

HISTORY

• Aching pain in the leg, worse at end of the day and on prolonged standing, relieved by lying down
• Bursting pain while walking (suggests deep vein thrombosis)
• Night cramps
• Ankle swelling towards end of day
• Itching of the skin
• Varicose ulcer at or near the medial malleolus

• Difficulty in standing or walking (suggests DVT)
• Symptoms of constipation or abdominal swelling (may indicate secondary varicose veins)

PHYSICAL EXAMINATION

A. INSPECTION

1. Varicose veins - Note the distribution, extent, and which system is involved (long saphenous or short saphenous). The long saphenous system runs along the medial side of the leg from medial malleolus to the saphenofemoral junction at the groin. The short saphenous system runs from behind the lateral malleolus to the popliteal fossa.
2. Skin changes - Pigmentation (haemosiderin deposition), eczema, lipodermatosclerosis, atrophie blanche.
3. Varicose ulcer - Usually located around the medial malleolus (gaiter area).
4. Oedema of the limb.

B. PALPATION

1. Temperature of the skin over varicosities (may be raised).
2. Tenderness along the course of the vein.
3. Saphenous varix - A blueish swelling just below the inguinal ligament that disappears on lying down; a cough impulse may be felt (Morrissey's test).
4. Fascial defects - Gaps in the deep fascia at the sites of perforating veins can be palpated.

C. SPECIAL CLINICAL TESTS

1. Trendelenburg Test (Brodie-Trendelenburg Test)

• The patient lies supine. The leg is elevated to empty the varicose veins.
• A tourniquet (or thumb pressure) is applied just below the saphenofemoral junction at the groin.
• The patient is asked to stand up.

• Trendelenburg I (positive) - Veins remain empty for 30 seconds after standing with the tourniquet in place, but fill rapidly from below when the tourniquet is released. This indicates incompetence at the saphenofemoral junction (long saphenous incompetence).
• Trendelenburg II (positive) - Veins fill rapidly from below even with the tourniquet in place. This indicates incompetent perforating veins below the level of the tourniquet.
• Double positive - Both above findings are present, indicating incompetence at both sites.

2. Multiple Tourniquet Test (Modified Trendelenburg)

3. Perthes' Test

• Purpose: To assess the patency of the deep veins.
• Technique: A tourniquet is tied around the upper thigh tight enough to occlude the superficial veins but not the deep veins. The patient is asked to walk quickly with the tourniquet in place.
• Interpretation:
  • If the communicating and deep veins are normal - the varicose veins will shrink (blood is pumped into deep system).
  • If the deep veins are blocked - the varicose veins will become more distended and the patient will complain of pain.
• Original Perthes' Test - The leg is wrapped with an elastic bandage and the patient walks. Severe crampy pain indicates deep vein thrombosis.

This test must be done before surgery - if deep veins are blocked, stripping the superficial veins is contraindicated as the patient will have no venous drainage.

4. Schwartz Test (Percussion/Tap Test)

• Purpose: To confirm continuity of a dilated varicose vein (used in long-standing cases).
• Technique: One hand taps/percusses the varicose vein in the lower part of the leg; the other hand is placed at the saphenous opening (saphenofemoral junction) in the groin.
• Positive: A fluid impulse (transmitted percussion wave) is felt at the saphenous opening. This indicates the vein is dilated continuously from below upwards.

5. Morrissey's Cough Impulse Test

• Purpose: To detect a saphenous varix or incompetence at the saphenofemoral junction.
• Technique: The limb is elevated to empty the varicose veins. The limb is made to stand and the patient is asked to cough.
• Positive: A palpable impulse is felt at the saphenofemoral junction on coughing, confirming incompetence at this site.

6. Pratt's Test

• Purpose: To locate the positions of incompetent leg perforators.
• Technique:
  1. An Esmarch elastic bandage is applied from toes to groin, emptying the veins.
  2. A tourniquet is applied at the groin and kept in place.
  3. The elastic bandage is removed from below downward.
  4. As the bandage is unwound from groin downwards, "blow outs" (visible bulges/varices) appear at the sites of incompetent perforators.

7. Short Saphenous Incompetence Test

• The saphenopopliteal junction is marked with a skin pen with the patient standing.
• The short saphenous vein is emptied by elevation of the leg.
• Firm thumb pressure is applied to the ink mark at the popliteal fossa.
• The patient stands and the pressure is released.
• Positive: The vein fills immediately, confirming incompetence at the saphenopopliteal junction.

SUMMARY TABLE

VARICOSE VEINS - Complete Viva & Clinical Guide

1. DEFINITION

2. APPLIED ANATOMY (High-yield for viva)

Long (Great) Saphenous Vein (LSV)

• Longest vein in the body
• Begins at the medial end of the dorsal venous arch of the foot
• Runs along the medial side of the leg, passes behind the medial condyle of the tibia and femur
• Passes through the saphenous opening (fossa ovalis) in the deep fascia to join the femoral vein at the saphenofemoral junction (SFJ), 3.5 cm below and lateral to the pubic tubercle
• Tributaries at SFJ: superficial circumflex iliac, superficial epigastric, superficial external pudendal, and deep external pudendal veins

Short (Small) Saphenous Vein (SSV)

• Begins behind the lateral malleolus
• Runs up the midline of the calf
• Joins the popliteal vein at the saphenopopliteal junction (SPJ) in the popliteal fossa

Perforating (Communicating) Veins

• Connect the superficial to the deep system
• Valves normally allow flow only from superficial to deep
• Important perforators: Dodd's (lower thigh), Boyd's (below knee), Cockett's (medial calf - most important clinically)

3. AETIOLOGY & CLASSIFICATION

Primary Varicose Veins

• Exact cause unknown
• Valve incompetence - either of the main trunk or communicating veins
• Weak venous walls allowing dilatation, which then causes secondary valve incompetence
• Very rarely: congenital absence of valves

Secondary Varicose Veins

Risk Factors

• Sex: Women > Men (ratio 10:1); hormonal factor (progesterone?)
• Age: Middle-aged most commonly
• Occupation: Prolonged standing - tram drivers, policemen
• Pregnancy: Hormonal + mechanical compression
• Obesity
• Family history: Strong hereditary component
• Previous DVT

Viva tip: Varicose veins are NOT found in other animals - it is the "penalty of erect posture" (S Das)

4. SYMPTOMS

• Worse towards end of the day
• Worse on prolonged standing
• Relieved by lying down / elevation

• Bursting pain while walking - suggests associated DVT
• Night cramps
• Ankle swelling (worse at end of day)
• Itching of the skin
• Cosmetic concern (the veins are unsightly)
• Varicose ulcer (medial malleolus area)

Viva tip: S Das emphasises that "it is not the varicose veins which produce the symptoms, but it is the disordered psychology which is the root of all evils." Asymptomatic varicose veins on one side and severe symptoms with minimal veins on the other side is possible.

5. CLINICAL EXAMINATION

A. INSPECTION (Patient standing)

1. Distribution of varicosities - long saphenous (medial) vs short saphenous (posterior/lateral) system
2. Skin changes:
   • Pigmentation (haemosiderin deposition - brownish discolouration)
   • Varicose eczema
   • Lipodermatosclerosis (thickened, indurated, fibrosed skin - "inverted champagne bottle" leg)
   • Atrophie blanche (white scarring)
3. Varicose ulcer - medial malleolus / gaiter area
4. Oedema of the ankle
5. Saphenous varix - bluish swelling below inguinal ligament (may mimic femoral hernia)

B. PALPATION

1. Temperature - may be raised over varicosities
2. Tenderness along varicosed veins
3. Fascial defects - palpable gaps/pits in deep fascia at sites of incompetent perforators (best felt with patient lying down and leg elevated)
4. Cough impulse at SFJ - if positive, suggests saphenofemoral incompetence (Morrissey's test)
5. Saphena varix - disappears on lying down; fluid thrill transmissible from below

C. PERCUSSION

D. AUSCULTATION

• Limited value except in arteriovenous fistula - continuous machinery murmur heard

E. Regional lymph nodes

• Inguinal nodes only enlarged if there is an infected varicose ulcer

F. Examine the other limb

• Always examine both limbs for bilateral involvement

6. SPECIAL CLINICAL TESTS (Most Viva-important)

1. Trendelenburg Test (Brodie-Trendelenburg)

• Patient lies supine; elevate leg to empty veins
• Apply tourniquet just below SFJ at groin
• Patient stands up

2. Multiple Tourniquet Test

• Three tourniquets at upper thigh, just above knee, upper calf
• Localises the level of perforator incompetence by observing which segment fills

3. Perthes' Test

• Deep veins patent → varicose veins shrink (calf muscle pump works)
• Deep veins blocked → varicose veins become more distended + crampy pain

Critical viva point: If Perthes' test is positive (deep veins obstructed), surgical stripping of superficial veins is contraindicated - the patient would lose their only venous drainage.

4. Schwartz Test (Percussion Test)

5. Morrissey's Cough Impulse Test

6. Pratt's Test

1. Apply Esmarch bandage from toes to groin (empty veins)
2. Apply tourniquet at groin
3. Remove Esmarch bandage from below
4. Re-apply Esmarch bandage from groin downwards
5. "Blow outs" appear at the sites of incompetent perforators as the bandage passes them

7. Fegan's Method

8. Short Saphenous Incompetence Test

• Mark the saphenopopliteal junction with a pen (patient standing)
• Elevate leg to empty SSV; apply thumb pressure to the mark
• Patient stands; release pressure
• Immediate filling of SSV = SSV incompetence

7. GENERAL EXAMINATION

Abdominal Examination

• Pregnant uterus
• Intrapelvic tumour: fibroid, ovarian cyst, cancer of cervix/rectum
• Abdominal lymphadenopathy

8. COMPLICATIONS

9. VARICOSE ULCER - Detailed Features (Viva favourite)

• Site: Lower third of leg, medial side (gaiter area), around medial malleolus; never above junction of middle and lower thirds
• Shape: Irregular, ragged edges
• Edge: Sloping, pale purple-blue in colour
• Floor: Pink granulation tissue (in acute); white fibrous tissue (in chronic)
• Discharge: Seropurulent with trace of blood
• Surroundings: Induration, tenderness, pigmentation, lipodermatosclerosis
• Healing sign: Faint blue rim of advancing epithelium at margin
• Compared to arterial ulcer: Venous ulcers are painless/less painful at rest; arterial ulcers are extremely painful

10. INVESTIGATIONS

11. TREATMENT

A. Conservative

• Compression stockings/elastic support bandages - for elderly, unfit, mild cases, pregnancy
• Lifestyle advice: avoid prolonged standing, elevate legs, weight loss
• Exercise - calf muscle pump activity

B. Injection Sclerotherapy (Fegan's technique)

• Sclerosant: Ethanolamine oleate, STD (sodium tetradecyl sulphate), hypertonic saline
• Principle: Inject sclerosant into empty vein → cause endothelial damage → thrombosis → fibrosis of vein
• Method (Fegan's): Perforator sites identified → patient standing (veins full) → injected → immediately compressed with foam pad + crêpe bandage for 6 weeks
• Indication: Small/medium varicosities, incompetent perforators, recurrent varices after surgery
• Complication: Skin necrosis (if extravasation), allergic reaction, phlebitis, DVT
• Disadvantage: Does not remove the source of incompetence; higher recurrence than surgery

C. Surgical Treatment (Trendelenburg's Operation + Stripping)

• Saphenofemoral junction incompetence
• Recurrence after sclerotherapy
• Failure of conservative treatment
• Complications (ulcer, bleeding)
• Patient preference

1. Saphenofemoral disconnection (Trendelenburg's operation): Groin incision → SFJ identified → LSV ligated flush with femoral vein → all tributaries at SFJ ligated and divided (to prevent recurrence)
2. Stripping of LSV: LSV stripped from groin to just below knee (not to ankle - lower LSV rarely diseased; saphenous nerve runs with it below knee and stripping risks saphenous nerve injury)
3. Stab avulsion (multiple phlebectomies): Small (2-3 mm) stab incisions over marked varicosities; veins avulsed with a hook

• Saphenopopliteal disconnection in popliteal fossa
• SSV stripped/avulsed

D. Endovenous Treatments (Modern)

• Endovenous Laser Ablation (EVLA): Laser fibre introduced into vein; thermal damage causes closure
• Radiofrequency Ablation (RFA): Similar principle with radiofrequency energy
• Foam sclerotherapy: Sclerosant mixed with air to create foam - greater surface contact
• Now preferred over open surgery in many centres

12. CAUSES OF VARICOSE ULCER NON-HEALING

• Arterial disease (check ABPI - ankle-brachial pressure index)
• Osteomyelitis of underlying tibia
• Malignant change (Marjolin's ulcer)
• Infection
• Poor compliance with compression

13. KEY VIVA QUESTIONS & ANSWERS